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RECEII'T OF DISTRIBUTION RELEASE AND INDEMNTTY AGREEMENT
This receipt, release, and indemnity agreement (hereinafter called the "RELEASE") is
given this o2.8 day of ~Ji„w. ~ 2009, by:
Internists of Central Pa
(hereinafter called the "CLAIlVIANT") to and in favor of KEYSTONE
GUARDIANSIiIP SERVICES, (ADMINISTRATOR) of the CYNTHIA N. STAGER
ESTATE (hereinafter Called "ADMINISTRATOR").
For the purposei of inducing the ADMINISTRATOR to make the distribution described
herein, and intending to be legally bound, the Claimant hereby represents, warrants, convenants
and agrees as follows:
1. Acknowledgment of Receipt -The Claimant acknowledges that he will receive of and from
the Fiduciary the following securities upon returning this Receipt & Release document
properly signed, wignessed and notarized to the department.
Cas~ - In the form of a check in the amount of $927.35
2. Release -AND TI~REFORE, the Claimant hereby does by these presents remise, release,
quit-claim, and fore er discharge the said Administrator, their heirs, successors and assigns of
and from the said ~ayments to me and of and from all actions, suits, payments, accounts,
reckonings, claims end demands whatsoever, for or by reason thereof, or of any other act,
matter, cause or t g whatsoever.
3. Indemnity Agreement -The Administrator has indicated a willingness to make a distribution
without the adjud~c tion by the Court. Accordingly, the Claimant agrees to indemnify the
Administrator and old them harmless, to the extent of any funds or assets received by the
Claimant from the'... dministrator hereunder, from and against the Claimant's pro rata share of
any and all liabil~ (including attorney's fees and other costs or expenses of defense) to
which the Admini~ ator may be subjected by reason of its administration of the account. In
connection with thi Agreement, the Claimant agrees to:
a) Refund or retu~{ tt, promptly upon the Administrator written demand, any funds or assets
distributed by t~ -e Administrator to the Claimant, if the distribution thereoc" is determined
at any time to ave been an erroneous or negligent distribution to the Claimant, whether
such error or n gligence was or was claimed to have been premised upon a mistake of
law or of fact.
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b) Modify and dish
Administrator
commenced, so
collect an error
such time as th
negligence.
4. Miscellaneous -
governed in all n
The provisions of
thereof shall be ~
provisions shall pe
hereof.
This Release shall
together with any al
IN WITNESS
first above ins
ice any otherwise applicable period limiting the time within which the
lion to collect an erroneous or negligent distribution must be
s to provide that the Administrator need not commence an action to
ins or negligent distribution to the Claimant until two (2) years after
Administrator shall have obtained actual knowledge of such error or
construction, effect, validity and performance of this Release shall be
is by the laws of the Commonwealth of Pennsylvania.
Release shall be deemed severable in the event that one or more
ed invalid or unenforceable, with the effect that the remaining
as if such invalid or unenforceable provision had never been a part
the Claimant his. heirs, representatives, s~accpssers, aed assigns
with respect to whom the Claimant is a natural guardian.
~REOF, the Claimant has executed and sealed this Release on the date
and the presence of at least two (2) witnesses.
BY:
Internists of Central Pa
Authorized Representative of Claimant
WITNESSES:
~I,. , /
(WITNESS ONE)
TWO)
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